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Friday, August 05, 2016

Spotlight: Should Hospitals Give Patients 'Unbanked Blood' To Save Lives?.

By MITHILESH MISHRA | INNLIVE

Unbanked blood transfusion is illegal. But short of blood, rural hospitals in Chhattisgarh say it is not unethical.

In April, a woman walked into a hospital in Baitalpur in Bilaspur district of Chhattisgarh, bleeding heavily. She was in her thirties, and had ruptured her uterus while delivering a baby at home in a nearby village. She needed urgent medical attention. When a van dropped her off on the highway, she trudged two kilometres to Baitalpur's Evangelical Mission Hospital – only to be turned away.

The hospital had an operation theatre and a gynaecologist, but no blood.

With buses plying only once in two-three hours from Baitalpur to Bilaspur, the district headquarters, getting blood from the blood bank takes at least four to five hours, if not a day. Without a quicker way to access blood, the hospital is not equipped to handle an emergency.

“She had a ruptured uterus and was anaemic," said Dr Kusum Masih, the medical superintendent of the hospital who is also a gynaecologist. "We could not operate without blood."

The doctors sent her to Bilaspur about 35 km away – but she died on her way there.

Eleven districts with no blood banks
There are 16 blood government-run blood banks and 30 private ones across 27 districts of Chhattisgarh.

The deficit of blood in the state is about 48%, said Dr SK Binjhwar, from the State Blood Transfusion Council. According to the World Health Organisation, a country should have a stock of blood equivalent to 1% of its population. By this standard, Chhattisgarh alone needs 25 lakh units of blood at any given point – but it usually collects 16 lakhs units a year.

What's more, 11 out of 27 districts in Chhattisgarh do not have blood banks – the largest deficit in any state in the country. In all, there are 81 districts in the country without blood blanks, according to data from the Union Ministry of Health and Family Welfare. Most of them are concentrated in Chhattisgarh, Jharkhand, Bihar, Uttar Pradesh and the North East.

For Chhattisgarh, a state with very high rates of anaemia, especially among women and children, the shortage of blood throws up multiple challenges.

According to the National Family Health Survey, more than half of the women of the state – about 57% – suffer from anaemia, as do nearly three-quarters, or 71.2% of children aged 0-5. About 2% of both women and children have severe anaemia, with a haemoglobin level below seven grams per decilitre of blood, for which most patients need blood transfusions.

Apart from this, about 60,000 children are estimated to have sickle cell anaemia, a severe form of the condition caused by a genetic blood disorder.

Anaemic women additionally face a higher risk of postpartum haemorrhage, which is a leading cause of maternal mortality in India. The maternal mortality rate of Chhattisgarh is 230 deaths for every 1,00,000 live births, as compared to the national average of 178.

Unbanked blood
For a rural hospital in Chhattisgarh, there is just one option in case of emergencies where blood is required – to refer a patient to a bigger facility. This often means that the person reaches the hospital in a critical condition, or dies on the way, as in the Baitalpur case.

Some hospitals are countering this by opting for an illegal way of giving blood, called unbanked direct blood transfusion. Under this, the blood of a willing donor’s that matches with the recipient’s group is collected, tested for infection with a rapid blood kit and then transfused without roping in a blood bank.

Take the case of a 40-year old woman from Shahdol district in Madhya Pradesh, who had been having extremely painful menstrual bleeding for nearly four months.

“Khoon girat rahe [I was bleeding all the time],” she said. “But, I would still have to work in our fields. How can I stop?” She was also not able to eat or walk and had severe chest pain.

On June 28, she somehow made it to a rural hospital in Chhattisgarh, which shares a border with Madhya Pradesh, travelling more than 200 km by train and bus with her husband and son.

When the doctors examined her blood, they saw she had a haemoglobin count of 4.6 – the normal range for women is between 12.1 and 15.1 – which meant she needed immediate transfusion. She also required an abdominal hysterectomy, as she had a large fibroid in her uterus.

In all, she needed three units of blood.

“I do not know how she managed to travel so far,” said a doctor at the hospital. “There is barely any oxygen reaching the organs. We have patients coming in with haemoglobin count of one as well. We can't direct such patients to other hospitals as their condition is already critical.”

The names of the hospitals and the doctors have been withheld because it is illegal to get blood from any other establishment other than a blood bank.

In this case, her son gave one unit of blood through unbanked direct blood transfusion, while two other units were arranged legally.

Doctors have been arrested in the past for using unbanked blood in other states.

Hospitals that practice unbanked blood transfusion usually have a list of donors in the community who can come and give blood when required. These donors are usually not paid – unless they demand payment and the situation is dire.

Insufficient blood
In 1996, the Supreme Court outlawed professional blood donation – that is, donating blood for money – and ordered the establishment of National Blood Transfusion Council to oversee and strengthen policies and systems governing blood transfusion in the country. In 1998, unbanked directed blood transfusion was disallowed.

In 2002, the council allowed the setting up of blood storage centres that were allowed to keep blood from licensed blood banks (but were not authorised to collect it). These storage centres could come up in villages and towns, while the mother blood banks would usually be in the district headquarters or cities.

In Chhattisgarh, there are 60 such storage units, mostly in community health centres, many of which do not use the blood at all and direct patients to go to other healthcare facilities. For instance, the community health centre in Gaurella, attached to the Chhattisgarh Institute of Medical Sciences in Bilaspur, has never approached the storage unit for blood. “I am not even sure it [the centre] functions,” said Dr VP Singh, who is in charge of the blood storage centre in the Bilaspur college.

Patients from community health centres often make their way to Jan Swasthya Sahyog, a non-profit in Ganiyari, near Bilaspur city. “Often, we see patients who are bleeding copiously after childbirth and are referred to us in that condition,” said Dr Yogesh Jain, one of the founders of the hospital.

Even hospitals that do use blood storage units, such as Jan Swasthya Sahyog, Shaheed Hospital in Dalli Rajahara in Chhattisgarh's Balod district and the mission hospitals, said they get insufficient units of blood.

“Our storage centre is attached to a mother blood bank in Durg,” said Dr Saibal Jana, chief physician of Shaheed Hospital. “We need about 150 units per month, but have barely about 35 units from the bank. Last month, they gave us only 10.”

Jan Swasthya Sahyog has an understanding with a private blood bank in the city, which gives them blood nearing its expiry date for free. This they use for scheduled surgeries, when the blood requirement is known.

Replacement donation
For every unit of blood taken from the bank, hospitals are supposed to send a replacement donor to the mother blood bank. This unwritten rule holds true even for hospitals that send relatives of patients to collect blood from a blood bank – private or public – for a planned surgery.

This is against the country’s National Blood Policy, which prohibits coercion in enlisting replacement donors and aims to phase replacement donations out.

Dr SK Binjhwar, from the State Blood Transfusion Council in Chhattisgarh, said that the state has 80% voluntary donation. Public health activists, however, said this figure is highly debatable and that more than 99% of the blood is likely collected through replacement donation.

“A hospital that has a blood storage unit organises blood donations camps for mother blood banks,” said Bhinjwar. “This is enough to meet the demands of the districts.”

The demand for a replacement donor for the mother blood bank hangs like a sword over the heads of patients’ family members.

Many donors from the hinterlands are not willing to travel to the nearest blood bank in the city to replace blood. It’s also difficult to find eligible donors in the immediate family – if a patient has anaemia, it’s likely that members of her family would also suffer from the condition.

Many also have an apprehension towards donating blood, fearing it causes weakness.

In such a scenario, touts who can provide ready donors for a price thrive. There are many such businesses in operation near blood banks in the state that provide donors for a sum of money to provide replacement units to the banks.

Rajesh Sharma, who runs the laboratory in Jan Swasthya Sahyog said that touts realise that people are looking for donors for replacement donation when they see an icebox in their hands. To combat this, Jan Swasthya Sahyog sends a patient's relative for replacement donation, they now send a letter (pictured below) that has to be signed by the blood bank.

People who are unaware about the dangers of remunerative blood donation – which has higher chances of infection – are willing to pay for the blood, despite having meagre resources.

In a rural hospital in Chhattisgarh, a 76-year-old was diagnosed with nectrotising fasciitis – a severe bacterial skin infection that spreads to the tissues quickly – on her arm. She had to be operated upon immediately to remove the infected tissues, but her haemoglobin count was just 6.3. During the surgery, the hospital collected blood via unbanked direct blood transfusion. But they were short of one unit.

“I do not know who will donate now...can we buy the blood?,” asked her daughter, who was tending to her.

While admitting that most units of blood are given only after a replacement donation, Dr Singh from the Bilaspur college's blood storage unit said: “We give blood to people who do not have replacements too."

"Usually if someone is an orphan with no family support, or someone comes without attendants, we give the bank without exchange too (referring to replacement donation)," he added.

Dr Singh said he had instituted a rule that no sickle-cell patients should be asked for replacement donors as he found out that the patients' families were bringing in professional donors, especially when the patient needed immediate treatment.

Unbanked blood ethical?
In a scenario where lack of access to blood banks has resulted in deaths that could have been avoided and helped touts flourish, doctors and healthcare activists practicing in rural areas have pushed for unbanked direct blood transfusion to be legalised, even as other activists argue that it shouldn't.

In June, Dr Yogesh Jain and Dr Raman Kataria from Jan Swasthya Sahyog wrotein favour of the practice in Indian Journal of Medical Ethics. They said that unbanked directed blood transfusion, if done by trained and certified healthcare teams, meets ethical standards and helps fulfil emergency blood requirements in rural areas.

In 2014, the Ministry of Health and Family Welfare met a delegation from the Association of Rural Physicians that sought to legalise this practice. Though the Drug Technical Advisory Board considered the proposal, it was eventually rejected.

The delegation argued that there the Drugs and Cosmetics Act allows unbanked directed blood transfusion for Armed Forces in border areas and peripheral hospitals, which should be extended to the same in emergency situations in rural areas too.

The Drug Technical Advisory Board, however, said that testing of safe blood requires a lot of infrastructure and trained manpower, without which the blood is likely to be infected. Besides, they said, it would be difficult to monitor them. They also said that the exemption given to Armed Forces cannot be given to rural hospitals.

“Are soldiers' life more important than a woman giving birth?" asked Dr Jain. "The implication of this policy is that either people go to the cities for treatment, or choose to die wherever they are. People who have to handle emergencies have to be equipped with technology and regulations should look into the ethical requirement of safe blood.”

An ideal solution, said doctors, would be to increase blood availability in the country by having a central blood bank in each district, with well-equipped storage centres.

However, activists working towards ensuring voluntary blood donation said that unbanked direct blood donation should not be allowed.

“All hell will break loose," said Vinay Shetty, from Think Foundation, Mumbai and a member of Voluntary Blood Donation Committee of Maharashtra State Blood Transfusion Council. "There will be no control over the blood in this country and we will go back in time."

The state has to take responsibility for the shortage of blood and has to ensure that no bank is short of blood, he said.

“The only answer to this is blood sufficiency," said Shetty. "Organising blood is not the responsibility of the patient. It is the responsibility of society at large. This is happening because there is no value to human life. Somebody in the state has to take charge."

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